Professional Disclosure

General Information

Welcome to my practice. The therapeutic relationship is unique in that it is a highly personal and at the same time, a contractual agreement. Given this, it is important for us to reach a clear understanding about how our relationship will work, and what each of us can expect. This document will provide a clear framework for our work together. My hope is that you read this information carefully as it will guide in your decision to seek services with me. Feel free to discuss any of this with me. Please read and indicate that you have reviewed this information and agree to it by filling in the checkbox at the end of this document. I suggest you also download a copy of this document for your personal records which you can do after signing as it will be available for download in the Documents tab of your Client Portal. You may also request a copy of this document from me at any time.

About Angelina “Angel” Thomson

I am a Licensed Marriage and Family Therapist Associate (LMFTA) in the state of Washington (#MG60975240). In 2019, I earned a Master of Science in Marriage & Family Therapy from Seattle Pacific University, Seattle, Washington. In 2016, I earned a Bachelor of Arts in Psychology from California State University, Monterey Bay, Seaside, California. I have experience in both community mental health and private practice settings, working with kids, teens, young adults, individual adults, couples, and families. I also have experience providing group therapy for teens and their families, and with adults. I was a volunteer youth leader for 10 years in which I mentored middle school and high school students. I have a Level 1 Certificate in Emotionally Focused Individual Therapy. I have completed the Emotionally Focused Couples Therapy externship. I have been a Certified Prepare Enrich Facilitator since 2014. As an Associate, I am under the supervision of an approved supervisor.

Contact Information

I can be reached by email, text message, phone call, or secure message through your Client Portal.

Email: angel@ojalaalliance.com

Office Phone: 425.529.7334

Client Portal: https://angelina-thomson.clientsecure.me/sign-in

I am generally in the office Tuesday – Thursday. In your Client Portal, you can view all your upcoming appointments, join your online session, access scheduling, and view/download billing documents. There may be times when I am with a client and cannot answer the phone, please leave a text or voicemail and I will get back to you at my earliest convenience. I check my email during my office hours. Text message and email correspondence should be limited to scheduling purposes only as it is not a secure method of communication. I cannot ensure the confidentiality of any form of communication through electronic correspondence. Additionally, as email is less secure, if you wish to correspond personal or clinical information via email you understand that there is potential for HIPAA breach and waive your right to HIPAA. While I try to return messages in a timely manner, I cannot guarantee immediate response and request that you do not use these methods of communication to discuss therapeutic content and/or request assistance for emergencies.

Therapeutic Orientation

I approach each client with openness, respect, and curiosity. I use a systemic lens in treatment that seeks to understand individuals and families holistically and contextually. I operate from a client-led approach in which I come alongside individuals to create a course of treatment that is tailored to honoring their strengths, beliefs, and values in achieving their unique, preferred outcomes. Together, we will create clear and defined goals, get clarity around presenting problems, and build upon achievements, always moving towards becoming the person you want to be and living the life you want to live. I have advanced training in Emotionally Focused Therapy (EFT) and also utilize techniques from Narrative Therapy, Dialectical Behavior Therapy (DBT), Trauma-Focused Cognitive Behavioral Therapy (TF-CBT), and other therapeutic techniques if they are helpful.

The Therapeutic Process

You have taken a very positive step by deciding to seek therapy. The outcome of your treatment depends largely on your willingness to engage in this process, which may, at times, result in considerable discomfort. Remembering unpleasant events and becoming aware of feelings attached to those events can bring on strong feelings of anger, depression, anxiety, sadness, etc. There are no guarantees in psychotherapy. I cannot promise that your behavior or circumstance will change. I can promise to support you and do my very best to understand you and help you clarify what it is that you want for yourself.

As part of our work together, you can expect the following from me:

• To be treated respectfully and non-judgmentally

• To be provided with a safe environment

• To be listened to

• To be provided with support and resources to facilitate the therapeutic process

• To be challenged in thoughtful and appropriate ways

What I expect from you is:

• To arrive on time for your scheduled sessions

• To inform me if you are going to be late or need to cancel your session

• To pay at each session

• To think about the work that we do outside of therapy

• To be open to the possibilities that are presented before you

Therapy Session Information & Rates

Your first appointment is an intake session where we will work together to identify your treatment goals. Subsequent sessions are scheduled once a week for 50 minutes on the same day/time weekly. I do not offer biweekly or monthly sessions.

The session rate for individual therapy is $250 per 50-minute session. The session rate for family and couples therapy is $275 per session. The Prepare Enrich Premarital Counseling Package is a one-time payment of $1700 due before the first session and includes eight 50-minute feedback sessions, the Prepare Enrich online assessment, the Couple's Report, and the Prepare Enrich Workbook. Additional 50-minute sessions may be added to the package for $275 per session.

Any report writing, letter writing, record preparation, phone calls, or meetings I attend on your behalf will be charged at $250 an hour prorated to duration of completion. I do raise my rates periodically. When my rates change, I will notify you in advance.

Consistency (Reschedule) Policy, Scheduling, & Missed Appointments

Consistency is key for the therapeutic process; your appointment time is set-aside specifically for you for as long as you want to be in therapy. I have what is called a Consistency (Reschedule) Policy. This policy protects the time I set aside specifically for you, as my client, and ensures that I have a consistent schedule that allows me to do my best work. Your designated hour is your financial responsibility; therefore, you agree to pay for your appointment, for the duration of our therapeutic arrangement, regardless of whether you choose to come. There are three exceptions:

1. You will be allotted one “free” cancellation each year of treatment following the start of services where you can skip a session with no requirement to pay. The “free” cancellation is often used for foreseeable events like vacations or unforeseeable events like emergencies, and can be used at your discretion. Notification prior to the start of your scheduled session is needed if you’d like to use your “free” cancellation.

2. If scheduling allows, you can “make up” for cancelled appointments in one of the weeks either before, during, or after the appointment you will be missing. This means there may be instances where we will be meeting twice in one week. Self scheduling is available through your Client Portal where you can cancel and reschedule appointments at your convenience. If a time to reschedule is not available within that 3-week timeframe, you are responsible for payment of the full fee for the missed appointment. I will make every effort to find a time for you. Please communicate with me about canceling/rescheduling or utilize the Client Portal any time prior to the start of your session, if you notify me after your scheduled session has begun, you will be charged for the session.

3. You are not required to pay for sessions that I cancel and, to the best of my ability I will notify you at least one week in advance for upcoming cancellations. I periodically take time off for vacation, seminars, or if I become ill. Generally, I do not work the weeks of Thanksgiving and Christmas. Additionally, I usually take off two weeks a year for vacation. Attempts will be made to give adequate notice of these events. If our appointment lands on a culturally significant holiday to you (for example Passover or Ramadan), you will not be charged as long as you let me now prior to the start of your scheduled session. Some dates will become unavailable because as a therapist I am required to complete a certain number of continuous professional development hours of training every year. I complete as many of these courses outside of regular office hours whenever possible. However, the best training is by live conference, and therefore there will be occasions when I have to cancel therapy to attend these trainings. You will not be charged for this missed appointment time.

Any appointment that is missed without notification will result in a charge for the full fee for the session and you will be charged for the session by the end of the day of your missed appointment. If you are 15 minutes late without prior notification, the appointment will be counted as a missed appointment. If you are less than 15 minutes late to the appointment, the appointment will still end at the allotted time. If I am late to our appointment, that amount of time will be added to the end of our session time.

All clients are emailed and/or texted an appointment reminder 48 hours and 10 minutes prior to their appointment time. Although glitches can happen, you are still responsible for attending your appointment regardless of whether you receive the reminders.

If you cancel or miss without notification two consecutive appointments, we will need to discuss your treatment goals and whether you are able to commit yourself to therapy at this time. If this occurs a second time, then another appointment will not be scheduled and a referral to another therapist will be provided.

If you decide to not continue therapy and forego the termination process, please email me or leave me a message on my voicemail, especially if you have appointments scheduled. This will allow me to release the time on my calendar and would be greatly appreciated.

Payment Methods & Credit Card Authorization: Ojalá Alliance PLLC accepts credit cards, debit cards, and HSA cards. You agree to provide your debit/credit card information, with the knowledge that the card will be charged at time of service for the session cost and for missed appointments and no show fees. The card information is secure in the Client Portal and is not visible in its entirety to Ojalá Alliance PLLC, and can be erased and removed from the Client Portal at time of service termination by your request.

Health Insurance: I am not contracted with any insurance companies and therefore, I do not accept insurance as a form of payment. My services are private pay only. I do not provide out of network billing services or superbills. You are financially responsible for all services rendered at the time of service.

Collection of Past Due Accounts: All unpaid accounts will be charged to the credit card on file with Ojalá Alliance PLLC for the balance due, and if the credit card on file is declined, the outstanding bill can and will be sent to collections. Upon being sent to collections, you forfeit the confidentiality of your personal information. No further services will be provided until the balance on your account is paid in full.

Good Faith Estimate

As of January 2022, the federal law called The No Surprises Act requires health care providers to provide clients with a Good Faith Estimate (GFE) of expected charges for items and services to uninsured and self-pay patients. The GFE is only an estimate and actual charges may differ. Additional items or services that are recommended must be scheduled or requested separately. The GFE is not a contract and does not require you to obtain the healthcare services that are being offered.

• The session rate for individual therapy is $250.00 per 50-minute session.

• The session rate for family and couples therapy is $275.00 per 50-minute session.

• The Prepare Enrich Premarital Couples Package is a one-time payment of $1700 due before the first session and includes eight 50-minute sessions. Additional 50-minute sessions may be added to the package for $275 per session.

• Sessions are held weekly.

• It is your decision how long you would like to be in therapy.

You have the right to initiate the patient–provider dispute resolution process if the charges you are actually billed substantially exceed the expected charges in this estimate. You may contact me directly if the billed charges are higher than this Good Faith Estimate, or you can start a dispute resolution process with the U.S. Department of Health and Human Services (HHS) directly. If you choose to use the dispute resolution process, that will not adversely affect the quality of health care services I provide to you.

Crisis and Emergencies

I do not offer emergency crisis services. My email/phone are not set up for 24/7 care and as such should not be used for urgent needs. If you are in an emotional crisis, you may call me, but I cannot guarantee that I will be able to answer. In the event that you are able to get a hold of me in an emotional crisis, if we are unable to resolve and/or create a plan after 15 minutes, at that point together we will begin to discuss additional resources (i.e. Crisis Line, going to the ER, etc.). In the event that I do not answer please call one of the following numbers for help or go to your nearest emergency room:

• General Emergencies: 911

• 24-Hour Crisis Line: 711 or 866.427.4747 (King, Pierce, Clark, Skamania, Klickitat, Grant, Okanogan, Chelan, and Douglas Counties)

• Pierce County Crisis Clinic: 800.576.7764

• The Crisis Clinic of Thurston and Mason Counties: 360.586.2800

• WA Recovery Help Line: 866.789.1511

• National Suicide Prevention Lifeline: 988 or 1.800.273.8255

If you are in a life-threatening emergency, immediately call 911, the police, or one of the numbers indicated above. If I believe that you need more intensive services, I will refer you to a therapist or organization that has the ability to provide treatment to meet those needs.

Contact During Vacations: If I take time off for any reason, I will notify you in advance and work with you to create a plan of care during my absence. If my leave will extend longer than 2 weeks, I will inform you of my backup therapist and relay their contact information to you prior to my leaving. In the event that you have an emotional crisis during this time please call the 24-Hour Crisis Line: 866.427.4747 and/or schedule an emergency session with the indicated backup therapist.

Social Media and Telecommunication: Due to the importance of your confidentiality and the importance of minimizing dual relationships, I do not accept friend or contact requests from current or former clients on any social networking site (Facebook, LinkedIn, Instagram, etc). I believe that adding clients as friends or contacts on these sites can compromise your confidentiality and our respective privacy. It may also blur the boundaries of our therapeutic relationship.

Client Rights & Choosing a Therapist

You have the right to privacy and you have the right to be treated with respect. You have the right and are encouraged to ask questions at any point about any part of the therapeutic process and to maintain an active role in the development of your goals. You have the right to work with a therapist who you feel will be most effective in helping you achieve your goals and meet your needs. You have the right to terminate therapy at any time, and I am happy to provide excellent referrals upon your request.

Please be aware that a therapist also has the right to terminate therapy for the following reasons: 1. if, as the facts of a case unfold, a therapist feels that it is in the client’s best interests to be treated by another professional who has specialized expertise in an area needed by a client; 2. if a therapist feels he or she is being treated abusively by a client; 3. if a therapist should lose objectivity in treating a client; 4. if a client repeatedly attempts to violate the boundaries of the therapeutic relationship; 5. if a therapist feels threatened in any way by a client; and/or 6. if a therapist is not being paid for services.

Confidentiality

Your sessions and records are legally protected and kept confidential. A record of your treatment will be kept at this office and you may request a copy of this record. The session content and all relevant materials to your treatment will be held confidential unless you request in writing to have all or portions of such content released to a specifically named person(s). Please note that in Washington State, youth 13 and older hold privilege of confidentiality and can consent to treatment. Limitations of such client held privilege of confidentiality exist and are itemized below:

1. If you threaten or attempt to commit suicide or otherwise conduct yourself in a manner in which there is a substantial risk of incurring serious bodily harm.

2. If you threaten grave bodily harm or death to another person.

3. If I have a reasonable suspicion that you or other named victim is the perpetrator, observer of, or actual victim of physical, emotional or sexual abuse of children under the age of 18 years.

4. Suspicions as stated above in the case of an elderly person who may be subjected to these abuses.

5. Suspected neglect of the parties named in items #3 and # 4.

6. If a court of law issues a legitimate subpoena for information stated on the subpoena.

7. If you are in therapy or being treated by order of a court of law, or if information is obtained for the purpose of rendering an expert’s report to an attorney.

Occasionally I may need to consult with other professionals in their areas of expertise in order to provide the best treatment for you. Your information will continue to remain confidential as I will not share any identifying information.

In couples and family therapy, the confidentiality and goals of each family member are equally important. To remain a supporter and effective facilitator of change, I do not aid in the keeping of secrets between partners and family members. I will, however, assist partners and families in creating clear, open, and honest dialogue that is consistent with the established care plan, clients' goals, and the safety of each person.

Your right to privacy and confidentiality is of the utmost importance to me, and I do not wish to jeopardize your privacy. If we happen to see each other in public, I will not acknowledge you first. However, if you acknowledge me first, I will be more than happy to speak briefly with you, but feel it appropriate not to engage in any lengthy discussions in public or outside of the therapy office.

HIPAA

Your records are confidential and protected, pursuant to the Health Insurance Portability and Accountability Act of 1996 (HIPAA). For more information on how your Protected Health Information may be used and disclosed please refer to the “Notice of Privacy Practices” document.

Text & Email HIPAA Consent

In order to use text messaging and emails for appointments and communications, HIPAA regulations require consent to this in writing. By signing this document, you consent to using text and/or email messaging with the full understanding that I cannot guarantee your confidentiality.

Legal Proceedings/Court Involvement

If you are involved in or anticipate being involved in legal or court proceedings, please notify me as soon as possible. It is important for me to understand how, if at all, your involvement in these proceedings might affect our work together. It is also important for you to know that I will not be a party to any legal proceedings against any current or former clients. My goal is to support my clients to achieve therapy goals, not to address legal issues that require an adversarial approach. Clients entering treatment are agreeing not to involve me in legal/court proceedings or to attempt to obtain records of treatment for legal/court proceedings when marital or family therapy has been unsuccessful at resolving disputes. This prevents misuse of your and/or your child’s treatment for legal objectives.

In the event that you might require my testimony or involvement in non-adversarial aspects of legal/court proceedings, I will do so only with your consent. I am unable to disclose any information pertaining to other family members or parties involved in treatment without their specific consent to disclose such information. Due to the special nature of legal proceeding and the abatement of clinical work a fee of $500.00 per hour will be charged to the client. I will not accept paperwork stating that another party is paying for costs unless costs are paid for in advance. Any fees accrued are the client’s responsibility to pay. This includes but is not exclusive to testimony, correspondence, preparation and consultation before, during and possibly after the legal proceeding.

Professional Issues

Therapists/Counselors practicing therapy/counseling for a fee must be registered or certified with the department of health for the protection of the public health and safety. Registration of an individual with the department does not include recognition of any practice standards, nor necessarily imply the effectiveness of any treatment. The purpose of the Counselor Credentialing Act (Chapter 18.19 RCW) is (A) To provide protection for public health and safety; and (B) To empower the citizens of the State of Washington by providing a complaint process against those counselors who would commit acts of unprofessional conduct. If you suspect that my conduct has been unprofessional in any way, please let me know so that we can resolve the situation together. To file a complaint against me, you can contact the Department of Health at the following address and phone number: Department of Health, Counselor Programs: P.O. Box 47869, Olympia, WA 98504-7869. Phone: 360.664.9098.

Minors

If you are a minor, your parents may be legally entitled to some information about your therapy. I will discuss with you and your parents what information is appropriate for them to receive and which issues are more appropriately kept confidential. In Washington State the age of consent for mental health treatment is 13 years of age. Youth 13 years or older will be responsible for providing consent to treatment, requesting records, and signing releases of information (if desired) to other Third Party persons/entities, such as insurance companies, medical professionals, school counselors and parents/guardians.

Termination of Services

Ending relationships can be difficult. Therefore, it is important to have a termination process in order to achieve some closure. The appropriate length of the termination depends on the length and intensity of the treatment. I may terminate treatment after appropriate discussion with you if I determine that therapy is not being effective or if you are in default on payment. I will not terminate treatment without first discussing and exploring the reasons and purpose of terminating. If therapy is terminated for any reason or you request another therapist, I will provide you with a list of qualified psychotherapists to work with you. You may also choose someone on your own or from another referral source.

Should you fail to attend an appointment for three consecutive weeks and/or I do not hear from you for three consecutive weeks, unless other arrangements have been made in advance, for legal and ethical reasons, I must consider the professional relationship discontinued and will close your file. If you ever wish to resume therapy with me, you are always welcome to contact me at that time.